Introduction: Exploring the Foundations of Psychiatry

July 30, 2019

As we discover new diseases of the brain that present with psychiatric symptoms, it remains incumbent upon us to remember the experience of patients and their families in the context of society at large.

Neuropsychiatry: Part 1

Although a biological basis for psychiatric disorders has now been firmly entrenched into psychiatric training, research, and clinical care, a strong understanding of the neuropsychiatric syndromes-both psychiatric manifestations of neurological diseases, and functional neurological disorders-has eluded standard psychiatric practice. The ACGME (Accreditation Council for Graduate Medical Education) sought to rectify this with the psychiatry milestones project, which identifies neuropsychiatry and neuroscience as among the score knowledge and skillset for psychiatrists.1

Unfortunately, our burgeoning understanding of neuropsychiatric disorders has escaped a generation. Moreover, even though neuropsychiatry is now recognized as a core of psychiatric residency training, most programs lack the faculty and resources for basic neuropsychiatric education.

This Special Report goes some way to rectify these deficiencies by providing state of the art overviews of some of the common neuropsychiatric syndromes. Unfortunately, many important neuropsychiatric topics such as autoimmune limbic encephalitis, behavioral variant frontotemporal dementia, the neuropsychiatry of epilepsy, rapidly progressive dementias, movement disorders and so on, could not be included. The neuropsychiatry of TBI was previously featured as its own special report.2

The recent discoveries of a variety of antibodies such as the NMDA-R antibody that can cause neuropsychiatric symptoms, and the various neuropsychiatric symptoms including delusions, hallucinations, and mania associated with the C9orf72 hexanucleotide repeat expansion, have focused our attention on the need to identify neurological causes of “psychiatric presentations.”3,4 As neurobiological research into psychiatric disorders has become the predominant model of inquiry, there have been calls for psychiatry to be reformulated as a “clinical neuroscience discipline” while some of my colleagues argue that all psychiatry is neuropsychiatry.5-7 I disagree.

To be sure, clinical neuroscience is a fundamental discipline for psychiatry. However, the social, cultural, political, and economic context is just as important to psychiatry. Furthermore, not all of the problems that psychiatrists treat are best explained in a neurobiological paradigm. Indeed, we are now learning that even for neuropsychiatric disorders, a narrow focus on the brain alone does not yield the secrets to our conundrums.

Take the example of Alzheimer disease. Long thought of as a paradigmatic neuropsychiatric disease, clearly explained by the presence of neuritic plaques and neurofibrillary tangles, this is no longer the status quo. Such pathology can exist in the context of normal cognition. Furthermore, it is clear that brain pathologies cannot explain the whole picture, and even hitherto undiscovered pathologies are unlikely to explain much of the variance in cognitive decline. Instead, it appears that social and psychological factors, nutrition, and other environmental contributors may provide important risk and resilience factors that confer vulnerability and protection to pathology.8

Neuroscience and neuropsychiatry provide a fundamental foundation to psychiatry. The reviews of neuropsychiatric syndromes featured in this Special Report including chronic traumatic encephalopathy, HIV-associated neurocognitive disorder, catatonia, tinnitus, autism spectrum disorder, psychogenic non-epileptic attacks, and tardive dyskinesia provide an excellent update on these disorders for the general psychiatrist. It may be tempting to view these syndromes as further evidence that psychiatry is merely a clinical neuroscience.

While psychiatrists must be able to detect and manage these conditions that exist in the hinterland between neurology and psychiatry, it is precisely because our training privileges the social, cultural, and psychological dimensions of care-in addition to the neurobiological-that psychiatrists are best placed to manage such syndromes. As Leon Eisenberg noted with concern: “The very elegance of research in neuroscience has led psychiatry to focus so exclusively on the brain as an organ that the experience of the patient as a person has receded below the horizon of our vision.”9p93

As we discover new diseases of the brain that present with psychiatric symptoms and clarify the neural underpinnings of well-described syndromes, it remains incumbent upon us to remember the experience of patients and their families in the context of society at large.

Disclosures:

Dr Datta is Assistant Clinical Professor, University of California, San Francisco, CA. He reports no conflicts of interest concerning the subject matter of this Special Report.

References:

1. Benjamin S, Widge A, Shaw K. Neuropsychiatry and neuroscience milestones for general psychiatry residents. Acad Psychiatry. 2014; 38:275-282.

2. Silver JM. Neuropsychiatry of TBI: an update. Psychiatric Times. 2019;36(4):15.

3. Kruse JL, Lapid MI, Lennon VA, et al. Psychiatric autoimmunity: N-methyl-d-aspartate receptor IgG and beyond. Psychosomatics. 2015;56:227-241.

4. Devenney EM, Ahmed RM, Halliday G, et al. Psychiatric disorders in C9orf72 kindreds: study of 1414 family members. Neurology. 2018;91:e1498-e1507.

5. Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. JAMA. 2005;294:2221-2224.

6. Reynolds CF, Lewis DA, Detre T, et al. The future of psychiatry as clinical neuroscience. Acad Med. 2009;84:446-450.

7. Ross DA, Travis MJ, Arbuckle MR. The future of psychiatry as clinical neuroscience why not now? JAMA Psychiatry. 2015;72:413-414.

8. James BD, Bennett DA. Causes and patterns of dementia: an update in the era of redefining Alzheimer disease. Ann Rev Public Health. 2019;40:65-84.

9. Eisenberg L. Were we all asleep at the switch? A personal reminiscence of psychiatry from 1940 to 2010. Acata Psychiatr Scand. 2010;122:89-102.

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